2020 FP NETWORK PRACTICE GUIDE
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FP NETWORK PRACTICE GUIDE 2020
C NTENTS Introduction 01 Family Practitioner Network Fees 02 Specialist Referral 03 Pharmacy Networks 04 Value-add Programmes / Services 05 Tools to help Network FPs 07 Healthcare Forensics 09 Contact Details 10
01 Dear Family Practitioner Fragmented healthcare has in the past resulted in inefficient, costly treatment for our beneficiaries. That is why we have introduced the concept of care co-ordination, as we believe that this not only improves the quality of healthcare for our beneficiaries, but also lowers overall health expenditure. As you are one of our Network FPs, we would like to thank you for the valuable services that you render to our beneficiaries. We would also like to make your task as easy as possible, which is why we have put together this guide. It aims to provide you with all the information you need to treat AECI beneficiaries effectively, including an overview of AECI’s value-add programmes and how these can complement your services to our beneficiaries. Also note that there will be a 4.5% increase in the AECI FP tariff rates with effect from 1 January 2020. If you have any questions, please call the Healthcare Provider Contact Centre on 0861 112 666. We look forward to partnering with you in 2020!
02
FAMILY PRACTITIONER NETWORK FEES
The AECI FP Network reimbursement model for 2020 will continue to include an enhanced fee, in accordance with the practice’s
REPI² category score as indicated in the table below, and will see a 4.5% increase in rates from 1 January 2020.
ENHANCED FEES
FP CONSULTATION RATES AUTOMATICALLY ADDED WHEN CONSULT IS PROCESSED
2020
(0190-0192)
REPI2 Cat 1 REPI2 Cat 2
AECI R402.00 R85.40 R38.50
The enhanced fee will automatically be added when the practice is reimbursed for consultations.
It is important that FPs adhere to their contract requirement to bill the AECI Society Rate, so that members are not faced with
unexpected co-payments.
03
SPECIALIST REFERRAL
WHY AECI REQUIRES A SPECIALIST REFERRAL
There is a growing trend of fragmented care, where a number of our beneficiaries are receiving duplicate treatment from multiple
doctors and providers. This leads to poor patient experience and unsatisfactory outcomes in providing safe, appropriate and
effective care.
AECI beneficiaries must therefore consult their Network FP BEFORE they make an appointment with a specialist, and the FP
must then obtain a referral number for the specialist referral. This will ensure that the patient is referred to the appropriate
specialist. Failing to do so will result in the beneficiary having to pay the specialist claim in full from their own pocket.
HOW TO OBTAIN A SPECIALIST REFERRAL NUMBER
• Contact the AECI Provider Call Centre on 0861 112 666 and use the Interactive Voice Recognition function to obtain a
referral number. You will need to have the following information at hand:
Your practice number, e.g. 1234567
Your patient’s membership number, e.g. 30300000001
Your patient’s beneficiary number, e.g. 00
Your patient’s date of birth in the format DDMMYYYY, e.g. 31121954
The practice type, e.g. 18 for a physician
The number of months that you want the patient to visit the specialist (between 1 and 6, e.g. 3).
A referral number will automatically be created for the beneficiary on the system from the date that you
created the referral and adding the number of months you have chosen to create, as well as an
end date for the referral.
• Specialist Referral can also be done via the web:
– Visit www.medscheme.com > login as a provider > click on Specialist Referral (and complete all required information).
• Quick reference guide for specialist practice types requiring a specialist referral:
SPECIALIST TYPE SPECIALIST TYPE DESCRIPTION SPECIALIST TYPE SPECIALIST TYPE DESCRIPTION
12 Dermatologist 28 Orthopaedic Surgeon
16 Gynaecologist 30 Otorhinolaryngologist (ENT)
17 Pulmonologist 31 Rheumatologist
18 Physician 32 Paediatrician
19 Gastroenterologist 33 Cardiology Paediatrician
20 Neurologist 36 Plastic and Reconstructive Surgeon
21/33 Cardiologist and Paediatric Cardiologist 42 Surgeon
22 Psychiatrist 44 Cardiothoracic Surgeon
24 Neurosurgeon 46 Urologist
04
PHARMACY NETWORKS
AECI has a large pharmacy network that consists of over 2 120 pharmacies, including Pharmacy Direct, Clicks, Dis-Chem,
Medi-Rite, Pick n Pay, Optipharm, Scriptwise, Netcare and Pharmacross, as well as various independent community pharmacies.
Network pharmacies have agreed to charge contracted dispensing fees, ensuring that beneficiaries will not be liable for co-
payments.
Please find information below regarding designated service providers, preferred provider networks and co-payments:
CHRONIC MEDICATION BENEFIT RULES
PHARMACY NETWORK • AECI has agreements with Clicks, Dis-Chem, Medi-Rite, Pharmacy Direct,
Pick n Pay and various independent pharmacies. AECI beneficiaries should be
reminded to make use of one of these pharmacies.
HOW TO APPLY FOR CHRONIC •P lease call the AECI Contact Centre on 0861 100 220 or email
MEDICINE aecicmm@medscheme.co.za
• You can also log onto medscheme.com > login as a provider > click chronic
application > insert membership number.
CHANGES OR UPDATES •C
hanges or updates to chronic medication are done telephonically by contacting
the AECI Contact Centre on 0861 100 220
CHRONIC FORMULARIES AND DISEASE •F ormularies can be viewed at medscheme.com > login as provider > click on
BASKETS clinical information > medicine management.
• Disease baskets can be viewed at www.medscheme.com > Login as a provider
> click lookup tool > disease basket lookup.
CO-PAYMENTS •C
o-payments can be avoided by:
- Ensuring the patient makes use of the contracted pharmacies; voluntary use
of non-network pharmacy will result in a 10% co-payment
- Prescribing in-formulary drugs; and
- Ask the pharmacist to substitute expensive medications with a generic
equivalent that will not attract a MPL co-payment.
Please contact the AECI Contact Centre on 0861 100 220 for any other chronic medication queries.
ACUTE MEDICATION BENEFIT RULES
PHARMACY NETWORK • AECI has agreements with Clicks, Dis-Chem, Medi-Rite, Pharmacy Direct, Pick n
Pay and various independent pharmacies. AECI beneficiaries should be reminded
to make use of one of these pharmacies.
• To find out which pharmacies have agreements with AECI, please call
0860 002 103
ACUTE FORMULARIES • Formularies can be viewed at medscheme.com > login as provider > click on
clinical information > medicine management.
CO-PAYMENTS •C o-payments can be avoided by:
- Ensuring the patient makes use of the contracted pharmacies;
- Prescribing in-formulary drugs; and
- Asking the pharmacist to substitute expensive medications with a generic
equivalent that will not attract an MPL co-payment.
Please contact the AECI Contact Centre on 0861 100 220 for any other acute medication queries.
05
VALUE-ADD PROGRAMMES/SERVICES
The following programmes/services have been put in place to enhance AECI’s offering to beneficiaries and to ensure quality
care at an affordable price. As FP, you can encourage AECI beneficiaries to make use of these programmes and services, where
appropriate.
IMPROVED CLINICAL PATHWAY SERVICES (ICPS) & JOINTCARE
ICPS and JointCare are the Designated Service Providers for AECI members and members will be liable for a R10 000 co-
payment for the voluntary use of a non DSP provider. ICPS and JointCare are groups of orthopaedic surgeons that specialise
in performing hip and knee replacements according to standardised clinical care pathways. These care pathways have been
developed in accordance with evidence-based outcomes to ensure that the quality of the hip and/or knee replacement is of the
highest standard and to ensure the best health outcomes.
ICPS or JointCare will ensure payment in full for the procedure, which will include the following:
• All hospital costs
• Surgeons and anaesthetist fees
• Prosthesis (subject to prosthesis benefit)
• Physiotherapist (pre-, intra- and post-operative)
If you have a patient who requires a hip and knee replacement, please call the AECI Provider Contact Centre on
0861 112 666 for details of ICPS or JointCare orthopaedic surgeons close to the beneficiary, and for a specialist
referral number.
DOCUMENTATION BASED CARE (DBC) BACK AND NECK REHABILITATION
PROGRAMME
The goal of the Back and Neck Rehabilitation Programme is to reduce the need for unnecessary surgery caused by chronic back
and neck pain and to restore normal function. The Back and Neck Rehabilitation Programme will, for most patients, decrease
pain, reduce stiffness and improve mobility.
All qualifying AECI beneficiaries have access to this programme. Beneficiaries who are eligible for the programme are proactively
identified by the AECI beneficiary risk management team. Eligible beneficiaries can also be identified by their FP, or they can self-refer.
AECI may impose a R5 000 co-payment should a member be admitted for back or neck surgery without consulting DBC.
The cost of the programme is covered by the Back and Neck Rehabilitation Benefit. Please note that this excludes the cost of
any other investigations or medication prescribed by a physiotherapist or medical practitioner, in which case acute benefits and
Society rules will apply.
Should you wish to enrol your patient in the Back and Neck Rehabilitation Programme, please call the AECI Call Centre on
0860 002 103 to determine whether your patient qualifies to be enrolled on this programme.
Should you wish to enrol your patient in the Back and Neck Rehabilitation Programme, please call the AECI Call Centre on
0860 002 103 to determine whether your patient qualifies to be enrolled on this programme.
06
MENTAL HEALTH PROGRAMME
Patient activation and empowerment is becoming an important focus area in the management of chronic diseases. However, this
may be a particularly difficult achievement in the patient with a mental disorder. In recognition of this, AECI offers a Mental Health
Programme that employs innovative solutions for empowerment, and leverages off social, family and workplace support.
Benefits of the programme, compared to usual care, are as follows:
• Greater reduction in mental health symptoms
• Greater rates of care for mental health
• Improvement in quality of life
• Less functional impairment
• Better patient satisfaction
• Better provider satisfaction
• Significant benefits in terms of absenteeism reduction
The Mental Health Programme follows an internationally successful model of integrating mental health care into the primary care
setting, through effective collaboration between family practitioners, specialists and auxiliary caregivers, and the introduction of a
Care Manager to help co-ordinate the process.
Should you require more information about the Mental Health Programme, or wish to confirm whether your patient
meets the criteria of the AECI Mental Health Programme, please call 0860 106 155.
PAED-IQ BABYLINE
BabyLine is part of PAED-IQ (Pty) Ltd, which has been in existence for 6 years and is a South African- based medical information
company, seeking to provide information and services to parents and caregivers that will enhance the level of care they are able
to provide to their children.
PAED-IQ partnered with the Paediatric Management Group of South Africa, a body that represents the majority of Paediatric
Specialists in private practice in South Africa. Through this collaboration, a database of information on common health conditions
in children was developed. This information is tailored to the needs of South African children and is endorsed by the Paediatric
Management Group of South Africa.
AECI has partnered with PAED-IQ to educate AECI parents and ensure their benefits last longer. BabyLine offers a paediatric
telephone triage service, which is available 24/7, 365 days a year. The service offers healthcare advice to parents with children
under 14 years of age and is delivered by skilled personnel (registered nurses).
AECI members will have access to this helpline, free of charge and can dial 0860 999 121 to make use of the service.
For more information on PAED-IQ, please visit https://paediq.com/aboutus.html
SMOKING CESSATION PROGRAMME
AECI offers the GoSmokeFree smoking cessation programme to members on the Comprehensive Option. GoSmokeFree is an
evidence-based programme that combines behaviour change techniques, one-on-one support and pharmacotherapy.
The programme starts with a Pre-Quit Assessment where a smoker’s readiness is determined. If the smoker is a suitable
candidate, a quit date is set followed by four weekly support sessions with Carbon Monoxide monitoring. AECI is encouraging
members on the Comprehensive Option who smoke to sign up for the GoSmokeFree service that is provided by trained nursing
sisters or pharmacists in participating clinics at over 200 pharmacies countrywide, including Dis-Chem, Clicks, Pick n Pay and
Independent Pharmacies.
All smokers can register once per beneficiary per year to have the GoSmokeFree consultation paid from the Smoking Cessation
Benefit. Where members may need pharmacotherapy as part of their management plan, AECI will allow them to claim for this
from the available Smoking Cessation Benefit. Extremely high nicotine dependency may however first require a referral back to the
Family Practitioner for consideration of a prescription for Varenicline/Bupropion.
For more information or to locate the nearest participating pharmacy, please visit www.gosmokefree.co.za. Alternatively,
please call the AECI Contact Centre on 0860 002 103.07
TOOLS TO HELP NETWORK FPs
ELECTRONIC MEDICAL RECORD
The Electronic Medical Record (EMR) is a digital version of a patient’s paper-based chart and aims to make it easier to share AECI
beneficiaries’ clinical and demographic information with FPs who are on the AECI FP Network.
The Independent Practice Association (IPA) Forum has provided their input with regard to the EMR.
The EMR provides FPs with the following administrative and clinical benefits:
ADMINISTRATIVE BENEFITS CLINICAL BENEFITS
• Decreased paperwork • Access to up-to-date patient information, including clinical notes
• Decreased storage cost and results
• More efficient billing • More effective diagnosis of patients
• Recording of clinical notes • Reduction of medical errors
• Reviewing and setting up appointments • Reduction of duplication of care
for the patient • Provision of high quality care
• Tracking of patient compliance
• Access to the patient’s medical history
• Electronic prescription of medication
The EMR was rolled out to a pilot group of doctors since 2017, to allow us to make further enhancements, based on feedback
from the pilot group. In future, the EMR will be made available to more healthcare professionals. AECI will keep you informed on
the progress of this exciting initiative.08
CARE PATHWAYS
Ensuring good clinical outcomes for our beneficiaries is a top priority for AECI. Equally important is equipping doctors with the
tools needed to achieve this. In consultation with experts in each chronic disease field, practising FPs and Society representatives,
a process has been started to develop Integrated Care Pathways for the major chronic conditions. The goal of this collaborative
effort is to develop care pathways that take into account clinical and financial implications, while at the same time being aligned to
beneficiary benefits and a primary healthcare approach.
Going forward, care pathways will be shared with healthcare professionals and will also be incorporated into the EMR.
To date, a hypertension care pathway and a diabetes mellitus care pathway have been developed and can be accessed by visiting
the Medscheme website at www.medscheme.com > Communication library > Communication > General Communication. Below
is an extract of the hypertension care pathway that has been developed.
BP BP
140-159/90-99 mmHg 140-159/90-99 mmHg
with09 HEALTHCARE FORENSICS AECI uses world-class analytical software, Insurance Fraud Manager (IFM) developed by FICO, which employs advanced mathematical techniques to detect suspicious and abnormal claiming patterns. This ensures that our beneficiaries receive the best and appropriate patient care at all times, whilst minimising the financial impact of fraud, waste and abuse. The claiming process for all healthcare professionals remains as is. Please continue to submit all claims as per the existing process. Valid claims will be assessed and paid. The claims data will then be reviewed to identify abnormal claiming patterns. If claims are found to be inappropriate, the relevant healthcare professional will be consulted to address the findings. Corrective measures will then be discussed and agreed upon to address the irregular claiming behaviour. Fraud, waste and abuse will continue to be addressed in a fair and transparent manner, which includes taking into account best practice and clinical necessity, where relevant. A healthy claims audit and forensic capability enables AECI to strengthen our ties with all healthcare professional bodies and ensures that we continue to work towards achieving our goal for holistic patient-centric and affordable care at all times. For any fraud-related queries, please contact the fraud hotline on 0800 112 811 or email fraud@medscheme.co.za
10
CONTACT DETAILS
SERVICE PURPOSE CONTACT
HEALTHCARE General queries related to AECI Email: aeci@medscheme.co.za
PROFESSIONAL CONTACT
CENTRE (IVR) INCLUDING
WEBSITE ASSISTANCE /
AECI PROVIDER CONTACT
CENTRE
CHRONIC MEDICINE Chronic submissions and queries Email: aecicmm@medscheme.co.za
MANAGEMENT
DISEASE MANAGEMENT Disease management updates Email: diseasemanagement@medscheme.co.za
FRAUD HOTLINE Fraud-related matters Email: fraud@medscheme.co.za
HOSPITAL PRE- All hospital pre-authorisations for Email: aeci.authorisations@medscheme.co.za
AUTHORISATION non-emergency events
SUBMISSION OF CLAIMS Submissions of claims for AECI Email: claimsmanagement@medscheme.co.za
beneficiaries
QUERIES OF CLAIMS Queries relating to a claim for a Email: queries@aeci.co.za
AECI beneficiary
ONCOLOGY SERVICES Oncology-related queries Email: cancerinfo@medscheme.co.za
AMBULATORY PMB Ambulatory PMB queries Email: aeciapmb@medscheme.co.za
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